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Trauma team leader Chris Hicks walks us through his step by step process of managing patients with penetrating chest trauma.
Sean D. - April 6, 2016 1:22 PM
Great segment guys, thanks. What about performing an ED thoracotomy at a non-trauma center? You guys touched on this a little, but wanted to know your thoughts on cracking the chest if you dont have a trauma surgeon at your shop. Does it all depend on local protocols? If your patient fits into that 30% that is salvageable can you transport your pt with an open chest to the nearest level 1 trauma center?
Rob O - April 14, 2016 11:40 AM
Hi Sean, here is Dr. Hick's reply...
if you have a potentially survivable patient (isolated stab to chest, VSA < 10 absolutely fits this category), and you have reasonable access to a trauma centre by way of inter-facility transfer, then the answer absolutely YES. closing an anterior cardiac wound (sutures, staples, foley) and resuscitating will often produce a very stable patient.
points to ponder though:
1. what's reasonable access? I use the LensCrafters rule -- transfer in about an hour (probably not practical if transport times well in excess of that)
2. the ideal incision: give yourself the best shot, the best exposure -- make a clamshell your initial approach; it's probably the ideal technique for the EP who does this infrequently
3. after ROSC -- leave in bilateral chest tubes, close skin with staples, provide adequate sedation/analgesia, don't forget to reverse any single-lung ventilation you've been doing to facilitate exposure
I know there's a lot more to the discussion, and you can't just up and do this in a ED or with a team who isn't familiar with the procedure. but in the end I think the patient-centered approach in young people with survivable injuries this is the right thing to do, and we need to build systems and understanding, including trauma and non-trauma hospitals, to facilitate that.
David H., M.D. (@BritFltDoc) - April 8, 2016 4:14 PM
Thanks Dr Hicks. What are you thoughts about the approach to a thoracotomy for a non-surgeon ? Left lateral or clamshell for all ?It seems to me that a clamshell, while obviously "dramatic" and a large incision, would give a provider who is probably very unfamiliar with the bloody mess and anatomy, the best chance of quickly identifying the heart and pericardium, and doing a pericardotomy and hole repair. Yet I feel with this approach, the shared mental model and team preparation is EVEN MORE important, as it will be a big mental hurdle for some to overcome and to commit too.
Thanks.
Rob O - April 11, 2016 10:11 AM
Here is the reply from Dr Hicks...
agree 100%. we are not thoracic surgeons -- why operate in a hole? the clamshell is the ideal incision for the non-trauma surgeon.
also agree that you can't just show up to work tomorrow and do a clamshell; you'll probably get letters if you do. building understanding and relationships with surgeons and shared mental models with your team is as important as the procedure itself.
K.M. - April 24, 2016 11:55 PM
I was hoping for more deciding factors to do, or not do, EDT at a non trauma hospital.... transfer times vs. surgical help available vs....?